Transitions in care (handoffs) are associated with increased risk for errors and adverse outcomes. The transition from the inpatient setting to ambulatory care may be particularly high-risk because the transition occurs over a longer period of time, communication may be poor, and the responsibility for the patient's care is not as clearly specified. Children admitted to intensive care units and infants born prematurely or with complex congenital abnormalities are surviving to discharge in growing numbers, and patients often require significant monitoring and coordination of care. Although studies of this transition to outpatient care in adult [unreadable] patients may inform the process in infants and children, it is not clear that the risks are the same or that the same approaches to resolving these problems will be appropriate. Our long term goal is to improve the health of pediatric patients with complex conditions by developing an efficient, widely applicable process that will identify error points and facilitate understanding of patient risk during this transition, and facilitate future development of interventions to mitigate these sources of error, using the transition from high-risk nurseries to outpatient follow up as the exemplar. Our overall hypothesis is that combining the prospective and retrospective approaches will accurately identify multiple high risk error points in the transition from inpatient to ambulatory care, and will result in appropriate plans for future improvement. Our specific aims are: 1) to conduct a prospective risk assessment using Health Care Failure Mode and Effect Analysis (HFMEA) and identify high impact error points and their origins that may occur in the care transition from the neonatal nurseries to ambulatory follow up; and 2) to use retrospective methods such as prompted spontaneous reporting, trigger events, selected chart reviews and targeted questionnaires to identify both latent and active errors and to corroborate and add to the findings from HFMEA. The refined model will be used to design specific interventions aimed at ensuring optimal transitions of care. Our findings should be broadly generalizable to organizations caring for children with complex health care needs as they transition from high intensity inpatient care to ambulatory follow up. Relevance: This project will improve infant health by integrating prospective and retrospective risk assessment to identify high risk points in the transition of infants from intensive care nurseries to ambulatory follow up and plans interventions to mitigate the identified risks. [unreadable] [unreadable] [unreadable]